30 January 2009

Washington State, like many other states, in deep in a budgetary crisis. This is largely, of course, due to the economic catastrophe that is envoloping the nation (GDP down 3.8% in 4Q 2008? Yikes!) Exacerbating the crisis is the cowardly leadership in Olympia, where Governor Gregiore, browbeaten by the anti-tax nuts, has pledged to pass a budget for the upcoming year with no new taxes. Which sounds great on the face of it until you consider that taxes pay for things.

Important things.

Things that will not exist if the government didn't fund them.

Take, for example, the Washington Poison Center.

Now I've ribbed them in the past, not entirely fairly, but I need to say this publicly: the Poison Center is an absolutely essential service and a critical element of emergency care.

You find your two-year-old kid sitting on the kitchen floor with an open bottle of Windex in front of him -- who do you call?

A patient comes in with an overdose of three different drugs the ER docs have never even heard of -- who do you call?

You splash an industrial solvent in your eyes and need to know how to decontaminate and whether to go to the ER -- who do you call?

Well, in Washington, you may not have anybody to call any more. Gov Gregiore, cutting an apocalyptic swath through all the state's social services, has halved the funding for the Poison Center, which will result in the end of the poison center's hotline services. So when someone comes to my ER in 2010 having ingested a massive amount of home-made colloidal silver, (yes, we really saw that a few years back and they were as blue as smurfs), we will have nobody to call for management advice and will have to muddle by with whatever we can find on Google.

If you are inclined, there is a page on the WA Poison Center web site explaining the crisis and providing links for the public to contact their legislators to avert this cut.

And when you hear the anti-tax activists braying about our taxes being "too high," make sure you ask them which essential services you are willing to live without. If you live in Washington, you may be about to find out.

This isn't terribly significant in and of itself (unless your kids are among the 11 million who are now eligible for the program), but it provides a clear outline of how the health care reform debate is likely to play out in the upcoming months. And it does look like the momentum for reform is continuing to build. Just two days ago, House Energy and Commerce Chair Henry Waxman said that "This is our time. ... We need to get this job accomplished this year and get a bill to the President." This is significant since Waxman (a good progressive) is the chair of the committee that is responsible for writing the health care reform legislation, and he is famous for his legislative skills (including most recently wresting control of the committee from dinosaur John Dingell). Given the status of the House GOP's rump caucus of dead-enders, the outlook for a "clean" and progressive House plan is good.

Much has alreadybeen written about the Baucus White Paper and the Kennedy subcommittee on health care reform, and I won't rehash it, other than to note that the policy outlines put forth do not include single payer, they do retain private insurance plans, and are non-incremental, universal coverage. Presuming that Franken is eventually seated, the Senate Democrats only need to peel off one GOP vote to end the all-but-certain filibuster, and there are a plethora of likely repulican candidates -- the moderates from blue states like Collins, Snowe, Gregg, and some vulnerable incumbents who may be worried about re-election like Voinovich and Specter. In fact, if the rumors are true, and Senator Gregg (R-NH) is tapped for Commerce Secretary, then his likely democratic replacement would represent the Democrats' 60th vote, and all that Reid would have to do is keep his caucus together, making a filibuster impossible. A tall order, perhaps, but if the plan looks likely to pass, the GOP moderates are all the more likely to jump on board, eager to be seen as being on the winning side of a popular reform.

All in all, the prospects look as good as they have since 1974 for truly comprehensive health care reform. It's going to be fun to watch this play out, and I only hope that Waxman and Baucus will pay some attention to the ruinous SGR formula and the perverse incentives of reimbursement that are driving primary care providers out of existence.

Cute. Street Anatomy is treasure. If you're not reading it regularly, you should be. They've beefed up their posting a lot lately, with some new contributors and it's really paying off. I would particularly recommend this not-entirely-safe-for-work post. Very cool stuff.

28 January 2009

Me: I've got this lady who needs to be admitted for [something uninteresting]. She looks OK, but her blood sugar is 450.Hospitalist: That sounds fine. Put her on the floor.Me: It'll be a while. You want me to give her some insulin in the meantime to get her blood sugar under control? Hospitalist: Sure. What type of insulin does she usually take?Me: There are different types of insulin?

Long silence.

Hospitalist: Yeeees. Me: Oh really? Damn, that's a new one.Hospitalist: You are kidding, right? Me: Not as far as you know.

Dead athletes' brains show damage from concussions[U]sing tissue from retired NFL athletes culled posthumously, the Center for the Study of Traumatic Encephalopathy (CSTE), at the Boston University School of Medicine, is shedding light on what concussions look like in the brain. The findings are stunning. Far from innocuous, invisible injuries, concussions confer tremendous brain damage. That damage has a name: chronic traumatic encephalopathy (CTE).

[...] CSTE studies reveal brown tangles flecked throughout the brain tissue of former NFL players who died young -- some as early as their 30s or 40s.

McKee, who also studies Alzheimer's disease, says the tangles closely resemble what might be found in the brain of an 80-year-old with dementia.

"I knew what traumatic brain disease looked like in the very end stages, in the most severe cases," said McKee. "To see the kind of changes we're seeing in 45-year-olds is basically unheard of."

The damage affects the parts of the brain that control emotion, rage, hypersexuality, even breathing, and recent studies find that CTE is a progressive disease that eventually kills brain cells.

There are such powerful incentives to play sports that it's unlikely that studies like this will prompt the dissolution of the NFL, but, well let's just say that my kids will not be encouraged to play organized football.

So, California ER docs are suing the state of California over low reimbursement rates from Medi-Cal, the state insurance program for the indigent.

Well isn't that interesting?

It's hard not to see this, coming as it does on the heels of the California Supreme Court's prohibition on balance billing, as a planned step in a coordinated strategy, especially as it involves several large ER groups. But I don't think so. It's reactionary -- in response to the recent budget cuts, I think, rather than being logically related to the balance billing issue. And I am not sure how well-thought-out it truly is. Sure, it provides a platform to get out the rhetoric that the ER safety net is unraveling, and it highlights the disgrace that is medicaid reimbursement nation-wide. But if the suit is without merit, constructed on a shaky legal theory, as I suspect it is, it will be dismissed or otherwise lost. That will neutralize any momentum towards reforming the Medi-Cal payment system and set the cause back quite a bit.

Maybe I'm wrong -- I hope so. Apparently the CMA won an injunction stopping a 10% across-the-board pay cut, so there may be grounds for this suit. But it's a big risk, and I hope it doesn't backfire.

Anyway, I can't see a less opportune time to file this suit -- the state's essentially bankrupt.

My little blog cracked 400,000 visits this week. Small potatoes in the world of the blogosphere, but still noteworthy. (I'm up to a "Flappy bird" in the TTLB Ecosystem, which I still think is by far the cutest way to stratify the blogosphere.) I also just passed my third anniversary blogging, 830 posts in all or what Andrew Sullivan would call, "a busy week." I don't put a lot of stock in anniversaries (as evidenced by the fact that I let that one fly past), but it's quite a while in blog-time.

I'd like to extend a real thanks to all the folks who have dropped by to read this blog, both those who enjoy my writing and opinions, as well as those who come by to disagree, and those of you who read via Google Reader or some other RSS service. I really appreciate your time, your feedback and your opinions. As Ezra Klein frequently says, "My commenters are smarter than me." Thanks for taking the time and effort to come here.

27 January 2009

I was chatting with a friend in our Karate class tonight. I know him reasonably well, but not much outside of class. We were talking about nothing in particular, and suddenly he gave a little start, and excitedly said, "Hey! I forgot to tell you. I was looking though my dad's medical records, and you were the doc who saw him in the ER last year!"

(I hate these revelations. There's always this sense of dread that the next sentence will be "and he came back the next day with a heart attack," or, "he said you were a total quack.")

"Oh really?" I affected a casual manner, "and how did the encounter turn out?"

"Great! He said you were awesome!"

"Woo-hoo!" (In my best Homer Simpson voice.) "So -- did I get the diagnosis right?"

26 January 2009

I was having an unusually good shift when the phone rang. It was busy, but I was working with the best nurses, and things were flowing well. Everybody I saw had a straightforward diagnosis, and the patients were all nice people.It was the radiologist on the phone. That should have been my first clue. Radiologists never call to chit-chat, or to give you good news. They never call to tell you someone's test was normal. But I was feeling expansive as I answered the phone, and the voice on the other end was a good friend of mine and one of the best radiologists I have worked with."Hey, Shadow," says he, "How's your day going, then?""Just wonderful," I responded, "and thank you for asking.""Well, I wanted to let you know that I'm about to ruin it for you. You know little Katie Jones that you ordered the ultrasound on to rule out appendicitis? The good news is that she doesn't have appendicitis. The bad news is that she has a twelve centimeter mass growing out of her right kidney and adrenal.""Oh my." I sat down at my desk and began jotting down notes."It looks to me that it is more consistent with a Wilm's tumor, but I can't rule out neuroblastoma.""That's bad.""Yup."

So I got to have the "your child has cancer" chat with the family -- the nicest people, who just weren't expecting to have that sort of hammer dropped on them. They didn't deserve that sort of news. Frankly, I find that conversation harder than telling people about a death. But what can you do? The whole time, the dad held his head in his hands and kept saying to nobody in particular, "appendicitis would have been OK."

I still think about Nathan Gentry every day. Nathan was the son of two of my closest friends, and he contracted neuroblastoma a few years back. Neuroblastoma sucks. It's an aggressive tumor, and after a terrible struggle, Nathan died about eighteen months ago at the age of seven.

Little Katie Jones probably has a Wilm's tumor. It's not quite as bad as neuroblastoma, with survival rates of about ninety percent. Ninety percent sounds pretty good, right? Great, even! Well, no. If you told me today that my six year old son had a ten percent chance of dying this year, that would be the absolute worst thing I could imagine. Well, I have a good imagination. It would still be terrible, especially in the light of the surgeries, chemo, and radiation that will be necessary to get there.

And I think about Henry. Henry has medulloblastoma, and he has relapsed. He's being treated at my alma mater and one of the greatest pediatric oncology centers in the world, but the challenge for relapsed medulloblastoma is a grave challenge.

My good friend Beth is a pediatric oncologist here at the local mecca, and a shit-hot researcher. She's working on potential therapies for medulloblastoma, and has got some promising leads. But funding is hard to come by, which is appalling but the truth. The cancer dollars mostly go to adult cancers, which are a lot more common and have more visible advocacy groups (no disrespect). Beth was the recipient of a St Baldrick's grant last year, which provided vital support for her to continue her research into treatments for kids like Henry, Nathan, and Katie.

So this year, as I did last year, I will be participating in the St Baldrick's program to raise funds for pediatric cancer research. I will be shaving my head at Fado's Pub in Chicago on March 13, sacrificing my beautiful locks to the cause of finding cures for these terrible diseases. Last year, we did the same, and Nathan's Network raised just about $40,000. You, my readers, were instrumental in helping us achieve that goal.

So, again, I ask you to consider donating whatever sum you can -- simply click on the image below and it will take you to the secure online donation site. The top donor will get first swipe with the razor, should he or she care to come to Chicago! All donors will receive an image of my glistening bald scalp and an extra helping of good karma.

25 January 2009

Two owls have taken up residence outside Second-born Son's classroom. The children are very excited about this. There was originally just one, whom the kids named "Moonface." Then a second one joined the first and was, accordingly, dubbed "Sunface." The teacher snapped this pic through the classroom window.

So, any ornithologists out there? What sort of owls are these? I'm too lazy to look it up.

PS. Owls always make me laugh, ever since I learned that one of the original (rejected) names for Monty Python's Flying Circus was "Owl-stretching time." That name was later used as an episode title. It still brings a smile to my face.

24 January 2009

Charlatan and conspiracy-monger Kevin Trudeau was ordered by a federal judge to pay a $37 million fine for his fraudulent advertising of secret, alternative cures (did you know coral can cure cancer? Well, apparently not, but it sure sounded great!)

It's nice to see the system work, and it's nice that it hammered this jerk to the ground, but it's a pity that only the truly egregious cases are actually punished. I can't for the life of me understand why Andrew Weil and Deepak Chopra are allowed to walk around as free men...

Over the years, from college to today, I and my family have at various times owned:Mac SE/30 (with a LC68030 processor running at a blazing 16MHz and a whole 2MB of RAM)Centris 610G4 PowerMacG4 Titanium PowerbookiBook G4G5 Powermac (Aluminum case)MacBook Pro (Intel processor)iMac (Intel)

I think I haven't missed any. We've also owned the original 5GB iPod, a 15GB 2nd-generation iPod, the second-gen nano, 4th-gen nano, 60GB video iPod and two iPhones. I still have them all, and they all work (and are used) except the original one.

Like some 60% of Americans, I watched the Inauguration live -- it was at work, and things were not too busy yet, so I was able to pop in and out of the break room and catch most of it. I was psyched to see Yo Yo Ma and Itzhak Perlman play before Obama took the oath -- I've been a huge fan of Yo Yo Ma ever since I first heard his rendition of Bach's 6 cello suites, which remains among my favorite music pieces. I was not enthused to hear that the piece they were playing was a John Williams arrangement, "Air and Simple Gifts," but it turned out to be elegant and in keeping with the atmosphere of the great event. One thing stuck me, though, watching their performance:

It was cold there, damn cold. The commentators had been talking about all the people being treated for hypothermia and all that sort of thing. I play fiddle (badly) and I know how hard it is to keep my violin in tune when there are temperature changes, especially dramatic swings (hot car in summer, or taking it outside in winter). I commented to the other folks there that I was stunned that they were able to play stringed instruments in those conditions, but the general consensus was that Perlman and Ma were just so awesome that they could pull it off.

Turns out that we were half right. The NYT reports today that the performance was recorded and played over the loudspeakers, while the musicians played along to their own recordings. "The conditions raised the possibility of broken piano strings, cracked instruments and wacky intonation," the Times reports. Yo Yo Ma said, “We also knew we couldn’t have any technical orinstrumental malfunction on that occasion. A broken string was not anoption. It was wicked cold.”

Also noted: they chose not to risk their Strads in the cold, using modern instruments instead. Yo Yo Ma considered using a carbon fiber cello (such a thing exists?) but did not because he did not want to distract with its unusual appearance.

22 January 2009

As an aviation junkie and an Obama fanboy, this is too cool, and I'm going to have to set the TiVO (Sunday 25 Jan at 8PM).

Ok, don't get picky with me -- it wasn't AFO at that time, just SAM 28000, as Obama was still only President-elect. It is only Air Force One when POTUS is on board.

I remember when I took my checkride for the private pilot's license, and we were coming back to land on the long runway at our home airport. The tower instructed us to wait for wake turbulance for a large military aircraft that had just landed, and after that, we were cleared for landing. As I flared over the numbers, the otherwise un-rufflable FAA examiner blurted out, "Holy Crap! That's Air Force One!" And indeed there was SAM 28000 coming back down the taxiway. We stared at it and I was totally distracted and muffed the landing, bouncing three or four times down the runway. The examiner just laughed and said, "That only counts for one landing!" Of course, the President was not on board at the time -- they close the airport when AFO is active. Still, it was cool landing immediately after that jet.

I heard that they're looking to replace it, and that the Airbus A380 is going to be in the running, since it's so much bigger. Boeing is going to counterbid with the (as yet nonexistent) 747-8. Boy, it would suck if Airbus got the contract, not just for national pride and all that, but because the A380 is such a hideously malformed beast of an airplane. The 747's silhouette is so noble and elegant in comparison. And Air Force One is just supposed to be a 747 -- it's the natural way! Either way, the new planes won't be acquired and operational until 2015 at the earliest.

Update: this is cool: Air Force One (Nat' Geo) has a twitter feed. Trivia questions and Q&A with the pilot of Force One tomorrow.

Some time ago, I was working with one of my partners, Owen, a young and earnest doctor, who possessed some of the best interpersonal skills of any of the doctors it has been my pleasure to work with. He just had a great way with people, and always did a wonderful job of communicating -- explaining what he was doing, what the diagnosis and plan were, and just making people comfortable and putting them at ease.

That evening, it happened that a Hispanic woman came into the ED with her husband; she was pregnant and having some discomfort. They were both extremely apprehensive about losing the baby. Owen went in to do a pelvic exam, and as always, he was kind and reassuring as he went through this uncomfortable procedure with them. They did not speak english, so he explained the process in spanish. He performed the speculum exam, and as he wrapped that up, he explained the next step, which would be a bimanual exam. That involves placing two fingers into the vagina and one hand on the abdomen in order to assess for cervical motion tenderness, uterine size or tenderness, and adnexal masses or tenderness. As he prepared to do so, he reassuringly told them, in Spanish, "And now I am going to feel with my fingers," which is a polite warning for a woman who may not have had this sort of exam before.

"Ahora voy a sentir con mi boca," he said.

This did not have the desired effect. The woman stiffened up, and the husband gasped in horror.

The nurse looked on in befuddlement, while the tech who was assisting with the exam and happened to be fluent in spanish doubled over with laughter and had to leave the room. Poor Owen was beside himself. Truth be told, his spanish was not terribly good (though much better than my own), and while he perceived that he must have not said the right thing he had no clue what his error was, and now he found himself standing between the legs of a patient, with his hands poised to perform the exam, but unable to proceed until the misunderstanding was resolved.

The readers of this blog who are fluent in spanish will have spotted his error, I am sure. After an interminable delay, the tech recovered himself enough to come back into the room and explain to the patient that "El doctor" had intended to say, "Ahora voy a sentir con mis dedos."

"Dedos" means "fingers." "Boca" means "mouth."

I cannot recall ever seeing someone as red as Owen was after that exam, and the nurses called him "Boca-boy" for months thereafter. Each and every time they did, he turned the exact same shade of red.

Owen has returned to his home planet now; he was too good for the likes of us. If he's reading this, he'll recognize himself, and I hope he knows we all still miss him.

21 January 2009

Leaving aside all the politics and policies, these are the photos, and there are many of them, that really get me choked up at the symbolism and the power of our first African-American president. Martin Luther King would have been 80 this week. What this day must have meant to the survivors of the Civil Rights era!

As usual, it is the Big Picture that has the best photo-summary of the day's events.

The case I posed last week drew a lot of thoughtful comments, most of them more or less spot-on. Answers and commentary below:

This upright abdominal x-ray shows multiple air-fluid levels, which are indicative of a bowel obstruction. Most bowel obstructions are small-bowel obstructions, caused by intraperitoneal adhesions. However, careful review of this shows dilation of the large intestine, indicated by the larger caliber of the air-filled segments and the transverse lines called haustra. The air extends into the left lower quadrant and pelvis, indicating that the obstructive lesion is quite distal, in the recto-sigmoid region. Therefore this is a distal large bowel obstruction.

The most common causes of this are, as correctly pointed out, sigmoid volvulus and colorectal cancer.

This abdominopelvic CT scan shows the obstructing lesion. Rectal contrast was administered and bright, undiluted contrast can be seen filling the ascending rectal segment (to the right of the arrows). The gut proximal to the lesion is markedly dilated with air-fluid levels, and there is some contrast present, indicating that the obstruction was not quite complete, though certainly high-grade.

This is consistent with an annular "napkin ring" or "apple core" adenocarcinoma of the colon, in which the cancer grows circumferentially around the lumen of the gut and the constricts inward.

In this case, the "high-dose narcotics" were indeed a red herring, which had caused other providers to dismiss his constipation and bloating as narcotic-related. The patient did diclose on history that he had been having scybalous stools prior to the obstruction -- small, pebble-like lumps of poop, which can be related to the reduced diameter of the distal colon.

Congratulations to anonymous 1/19 2:26AM as the first correct response: you are hereby awarded my everlasting respect and admiration.

Popsci has an incredible picture of the inauguration seen from space. The pic has a resolution of half a meter; the little black dots are people, and they are largely clustered around the JumboTron screens watching the action.I love even ordinary satellite imagery. This is way cool.

20 January 2009

So this is Obama's new Presidential Limo. Ugly as hell, but brawny, it is referred to colloquially as "the Beast," since it apparently does not have an official model name. Armor-plated up the yin-yang, all sort of high-tech goodies (most of which are not revealed, of course), and just cool as heck, for a gadget guy like me. Fun tid-bit -- only the driver's window opens, and that only three inches. Makes sense; all the other windows are like five inches thick.

Here's the odd thing. You notice in the above graphic (obtained via DKos) there is a blurb titled "Defense Accessories," which reads in part, "Bottles of the President's blood kept on board in case he needs an emergency transfusion."

Um, really?

OK, I'll grant a little literary license -- I am sure it's not actually the President's blood for auto-transfusion, but just pre-crossmatched blood.

But still.

It just seems bizarre. Yeah, I know, I remember that episode of West Wing when President Bartlett got shot and they had to hustle him to the hospital and maybe it would have been good to have some blood if he needed it. (And my memory fails me -- didn't something similar but more serious happen in real life in 1981? I must be imagining it.)

So I guess it's not totally paranoid. It's hard to imagine the POTUS would ever be far enough from medical facilities that, should he need emergency care it would not be faster to drive him to the designated Presidential ER (there always is one, wherever he is) than screw around with trying to transfuse him in the field. In fact, from a simple trauma perspective it would make better sense to have several liters of warmed crystalloid in the car.

The best argument I can think of for keeping crossmatched blood around at all times is that if something happened (God forbid) and they took him to the local ER, there would be safe, screened, crossmatched blood that they could bring in with him to more immediately transfuse, ensuring at least a temporary supply of blood and decreasing the delay to transfusion.

18 January 2009

A sixty-seven year old man on chronic high-dose narcotics with subacute onset of constipation and bloating presents with abrupt onset of severe pain, which is poorly localized and comes in waves. He reports no bowel movements in six days, and is uncertain whether he is passing flatus. There is no vomiting. Vital signs are normal, and exam shows a protuberant abdomen, tense and minimally tender to palpation, with normal bowel tones. Rectal exam shows an empty vault.

16 January 2009

I've tried to steer clear of politics since the election. No need for gloating or triumphalism, and I just haven't had too much to say about the transition news, most of which has been pretty inside baseball. But now that the inauguration is imminent, I am starting to get excited. I'm excited to have Obama take office, and I'm excited to be rid of that pathetic failure of a predecessor. I had planned on writing a long vituperative post explicating the evidence that Bush has been the worst president of my lifetime, or perhaps just updating this list from two years ago. But I just don't have the emotional energy for that sort of vitriol just now. I'll let Froomkin say it for me:

He took the nation to a war of choice under false pretenses -- and left troops in harm's way on two fields of battle. He embraced torture as an interrogation tactic and turned the world's champion of human dignity into an outlaw nation and international pariah. He watched with detachment as a major American city went under water. He was ostensibly at the helm as the worst financial crisis since the Great Depression took hold. He went from being the most popular to the most disappointing president, having squandered a unique opportunity to unite the country and even the world behind a shared agenda after Sept. 11. He set a new precedent for avoiding the general public in favor of screened audiences and seemed to occupy an alternate reality. He took his own political party from seeming permanent majority status to where it is today. And he deliberately politicized the federal government, circumvented the traditional policymaking process, ignored expert advice and suppressed dissent, leaving behind a broken government.

Yeah, that pretty much sums it up. Obama's got his work cut out for him -- there's a lot of damage to the country, the government, and the constitution to be put right.

Seriously, how evil were Bush and his cronies? They tried to shut down the Voting Rights division of the Justice Department. Voting Rights. In this day and age. How can you be opposed to voting rights? I do hope there is some accountability for these criminals.

15 January 2009

Following up on my post the other day about California's ban on balance billing, it's clear to me that Emergency Medicine as a specialty has to come up with a plan to address this issue, or it's just going to kill us, state by state. Because the insurers have seen this go down now in several states, and with California now setting the standard, it's certain that they are going to try to replicate this strategy elsewhere.

Fighting specific balance billing legislation and regulations as they crop up in your own state is a reasonable approach, but it seems to me like a stop-gap, and ultimately a losing strategy. The Supreme Court of California rendered an judgment that may have been in accordance with California law, but more importantly, followed the judgment that has been rendered by the court of public opinion. The public, the media, and lawmakers are not going to allow disputes which are perceived as putting patients in the middle, or punishing patients for disputes to which they are a third party, especially when it relates to emergency care. If lawmakers are therefore obligated to choose who the winners and losers will be in the dispute between doctors and insurance companies, they will reliably prefer the industry which lavishes millions of dollars in campaign contributions. (That ain't us.)

Forgive me for engaging in RealPolitik here. I think it's not so bad that patients might have to pay for services rendered in some cases. I think that we should be able to negotiate our prices. I think that the insurers are the bad guys here, trying to drive prices down to pad their profit margins. But I also think that if we keep making these arguments, we are going to lose. So principles and ideals must bow to necessity in formulating a strategy.

And a new strategy is going to be necessary. By which I mean that we should not concede the point outright, but instead get out there ahead of it and have an argument to make to legislators which takes the moral high ground, protects patients, but also protects the integrity of the social safety net that the Emergency Departments represent. Remember that legislators and the public in general tend to view ER docs favorably -- we are the heroes and the good guys. If we come out in advance with a position that vulnerable patients need to be protected, we will have a much more receptive audience than if our stance is "screw patients, we don't care who pays but someone has to."

A successful strategy, I think, would be based on the following principles:1. Patients' interests should never be put at risk over financial disputes. The insurers need to live up to their obligation to cover their beneficiaries' care. The party line should be that out-of-pocket payment from patients is an unacceptable solution -- all payment should be from the insurers, and we are acting as the patients' advocates. Is this cheap demagoguery? Maybe -- I don't know. But it's salable, and potentially more effective than what we've been arguing. It is also consistent, since we have been lobbying for years for insurance companies to pay us directly rather than to bill the patient and have the insurers reimburse them.2. Define, by region, what FAIR PAYMENT is. Given the way it has been manipulated by its parent, UnitedHealth, I would not use the discredited Ingenix database for this purpose. However, other mechanisms exist to capture the data regarding "Usual, Customary, and Reasonable" (UCR) charges for ER codes in a given region, and that should be the starting point for negotiations.3. The emergency safety net is at risk, and our rhetorical focus must be on preserving it. The point to emphasize with legislators is that our goal is to obtain a revenue-neutral solution. Fair Payment should not result in crippling financial losses to already-stressed emergency providers (I didn't see a lot of A's on the Emergency Care report cards). Emergency care providers are not in search of a windfall, but a solution which takes patients out of the middle while preserving the status quo in terms of overall costs.4. Link an end to balance billing with a legislative guarantee that insurers must provide fair payment for care provided under EMTALA's obligation, or, alternatively, some mechanism to arbitrate the fair value of emergency care, taking into account the massive infrastructure cost of uncompensated care provided to the indigent.5. Increase the collective bargaining rights of physicians. The insurers have the advantage of knowing what every provider in the state is paid, whereas physicians are prohibited by anti-trust legislation from even discussing their fees with one another. This asymmetry of information creates an unlevel playing field when physicians try to negotiate with insurers for fair payment. If anti-trust laws cannot be made to contain a safe harbor for physicians to share information or collectively bargain, then trusted independent bodies (such as the state office of budget management) could perform that function in a blinded fashion.

The reality is that when the insurance industry brings the balance billing issue to the legislature in your state, they are going to drop a bill, pre-written, on the desk of a friendly representative that is going to be terribly adverse to the interests of the physicians. If EM, as a specialty, is going to have a chance in hell to fight it, we need to offer a palatable alternative. Either this alternative would be enacted and improve the situation, or create gridlock and preserve the status quo. When patients are being hurt, digging our heels in and obstructing will win us nothing.

14 January 2009

13 January 2009

The scene: a major urban ER at 3AM. Four nurses are huddled at the nursing station, reviewing the forthcoming schedule. Three or four patients populate the near-empty department. Your author sits to the side, studiously completing charts. The lights are dim, reflecting the lack of work to be done and the mid-night torpor of the staff.

The medic phone shatters the quiet, jolting everyone awake. The charge nurse activates the speakerphone. "Central Hospital, go ahead."The response comes in a drawl worthy of a good ol' boy, "Yeah, Central, this is Ron on Medic 31 with a report for y'all.""Medic 31?" The nurse responds, "You're pretty far from your home area, aren't you?""Well, I called Big Hospital but they sent us your way.""But they're not on diversion -- they're not even busy!" protested the nurse. Sighing, she gave up, "Whatever. Go ahead. What do you have?""I've got ol' Bill Boozehound. He was found unsresponsive on a park bench again.""Great," the nurse grumbled. "Now I know why they diverted you. Anything up with him tonight, or just drunk again?""Nah, just drunk. He looks pretty bad. I think he crapped himself, and he's soaked in urine. And there are an awful lot of bugs -- I don't think they're maggots, but they're pretty big to be lice.""Well, that's just lovely. What's your ETA?""We'll see you in five."

The phone is hung up and much grumbling and indignation ensues from the nursing staff. Where the hell does Big Hospital get off dumping their crap on us? Especially because they're not even busy! Foot stomping and irritation flare. A bed and decontamination gear are prepped. This night, the consensus is, just got ugly. Bill is well known to us all, and is vile and unpleasant, obnoxious and can be a real handful when he's had a few. Which is every night. Five minutes pass, and there is no ambulance. Ten minutes turn into twenty and still they do not show. The tension mounts. Finally the phone rings again, and three nurses pounce on it.

"Central Hospital.""Hey there Central, this is Ron on Medic 31 again. I'm sorry to bother you, but can you refresh my memory: exactly where are you all located?""You mean," the nurse stammers in disbelief, "Our address?""Yeah, it's late and I think I just spaced. Where are y'all at?""We're on 12th and Grand.""Oh, God, that's right. Damn. I was heading north on 99." (muffled) "Hey Tim, turn the rig around -- they're south!""Are you kidding us? You're lost?""No, no. We're good now. Thanks for you help. We'll see you in ten.""Central out."

The phone is slammed down and heads shake at the absolute morons they let drive ambulances these days. How in the hell do you get lost going to the biggest hospital in the county? Idiots. The waiting recommences. But still no Medic 31. In another twenty minutes, the medic phone rings again. This time, the nurses are a little more tentative in answering:

"Central Hospital?""Oh, hi there. This is Ron again. From Medic 31. Hey, Bill was getting a little queasy and we thought some donuts would settle his stomach, so we stopped at Henry's to get some. Y'all want we should pick you up some, too? They're fresh.""You're stopping for donuts with a patient in the rig?!?""Ah, it's just Bill. He's fine. Y'all like chocolate?" (silence) "Well, never mind. We'll just get you an assortment. See you in five."

It is with utter disbelief that the phone is deactivated. Donuts? Oh. My. God. This staggers the imagination, and the poor charge nurse just holds her head in her hands. To nobody's surprise, Medic 31 fails to arrive in five minutes. Or ten. Or twenty. The phone rings again. The nurses look at one another, but nobody dares answer it. Finally, on the fourth ring, someone switches it on.

"Central Hospital, go ahead."A clipped staccato voice comes forth, with military precision: "Central, this is County Dispatch. We're looking for Medic 31. They're been MIA for over an hour. Have you heard from them?"

That opened the floodgates, and the whole story spilled out in torrents from the aggrieved and astonished nursing staff. I'm not sure how anyone could have absorbed it from the confused welter of voices, but Dispatch took it in and promised to look into the matter. Medic 31 never did show up.

A bit later, my friend and partner, Dr PB, called over from Big Hospital (we staff both), where he was working the overnight shift. "Hey Shadow, how's it going?""Pretty dead. You?""Totally dead. Anything interesting?""We had this weird situation with Medic 31...""You don't say." He slipped into a drawl, "Say, y'all like chocolate donuts? 'Cuz I like chocolate."

He waited for a moment while the implication sank in on me.

"I see. I see. Well played, my friend. Well played.""See you are conference tomorrow?""See you there."

12 January 2009

Written with the modesty and restraint that most observers agree is my hallmark.

But you must admit, it's terribly satisfying when you see something on the x-ray that the radiologist does not. In this case the initial reading of the above film was "nondisplaced fracture lesser tuberosity." I noticed the little cortical discontinuity on the medial aspect indicated by the "hey dummy sign," (the red arrow) which I thought indicated that the fracture extended all the way through the surgical neck. A diplomatic call to the radiologist, a couple of additional views later, and the diagnosis was confirmed, as seen below. In fairness, it's a lot easier when I have seen the patient and they have not, but that doesn't diminish the pleasure from out-experting the expert!

09 January 2009

Congratulations to the twelve commenters who correctly identified the abnormal findings from the abdominal radiograph in this previous post. It was indeed pneumatosis coli due to acute mesenteric ischemia.

I will admit that this was not a terribly difficult diagnosis for me to make since the patient began the conversation saying "That nice Dr Vascular put a stent in my IMA on Tuesday, and I was doing just fine until today when suddenly I started hurting."

I wish all my patients were as clear and direct as that.

Pneumatosis is a collection of air within the intestinal wall in very small vesicles; it is almost universally associated with necrosis of the affected area (aka dead gut). It's a very ominous finding, as the mortality rate for mesenteric ischemia is very high. I believe that the mortality is much worse for small intestinal ischemia, due to the larger distribution of intestine covered by the SMA.

This case had a surprisingly happy outcome. A stat angio showed that the stent was patent, so the patient proceeded to the OR and had an uneventful hemicolectomy and made a full recovery. The ischemia was presumed to be from diffuse distal vascular disease which was not amenable to reconstruction.

The court on Thursday struck down a practice known as "balance billing," in which doctors and hospitals seek to collect from patients any amounts that their managed-care plans refuse to pay. Instead, the providers must either absorb the costs themselves, or get the insurance companies to pay.

Balance billing is controversial because patients are sometimes hit with emergency-room bills because they go to the nearest hospital or other medical facility regardless of whether it accepts their insurance. Health-care providers argue that they need some way to guarantee that they can be paid for their services.

In its decision, the California Supreme Court overturned a lower-court ruling and found that billing disputes over emergency medical care must be resolved solely between providers and health plans.

Patients are "hit" with bills! Oh Noes! Isn't that awful that patients might actually have to PAY for services rendered? That's just not American! We need to stop that. Tell you what, here's a reasonable solution, let's just let the insurance companies decide what to pay. They know the cost of care and I'm sure they'll be fair, don'tyouthink?

Gaah.

For those of you who don't run physician practices, this is a disaster in the making. Currently, if an insurer does not want to pay a fair amount for our services, we drop out of their network (go "non-par") and the patient will get a bill for the full charge for their ER visit. That averages about $400. The insurer will pay some random amount, and the patient is responsible for the rest. Patients hate this, so they complain to their employer and insurer, and in most cases the complaints will bring the docs and insurer back to the table to find a common ground. In those cases, the docs will usually allow a discount from their gross charge, anywhere between 10-40% depending on the market clout of the insurer, in return for prompt hassle-free payment.

Now, however, the option of going non-par in California is simply off the table. If that happens, the docs have to accept whatever pittance the insurer pays as full payment. But the doctors can no longer negotiate with insurers either, since they no longer have any credible leverage to demand reasonable payment for their services, so they wind up having to accept whatever pittance the insurer offers.

The result of this is that all commercial payers in CA are going to trend rapidly down to the medicare rate, which is barely at or below costs for most docs. You might as well just go to single payer, since then at least the crappy reimbursement would be slightly offset by the fact that medicare never denies claims, which I am sure the insurers will continue to do. Either way, it's terrible news for physicians. It's particularly bad for ERs, as it is ER docs who generally have the most trouble with this balance billing issue. See, if you are an office doc, and a patient wants to make an appointment, you can check their insurance in advance and if you don't take their insurance, they either get sent elsewhere or have to pay cash. But ER docs have to take all comers; under this ruling they now must either contract with every single insurer out there or run the risk of non-payment as out of network providers.

CalACEP and CalAMA need to be all over this. They need to get themselves some well-connected lobbyists in Sacramento and get some legislation which would restore some balance to the negotiations.

It's a pity that none of the players in this dispute were able or willing to make the case that is is acceptable for patients to bear some financial responsibility for their health care. That's the real underlying problem here -- the entitlement mentality that health care must always be free. It boggles my mind that the Cal Supreme Court agreed with this. Maybe Symtym can explain the reasoning behind the legal decision, but that won't change the fact that it was wrong.

08 January 2009

From the Boston Globe's Big Picture series. On a purely technical level, speaking as a (very) amateur photographer, these are just stunning. The timing to capture the instant that a missile explodes, or the moment just before impact -- it leaves me breathless. From a political and humanitarian level, they are pretty sobering.

A seventy-six year-old man presented with a fever and the sudden onset of abdominal pain. He was tachycardic and hypotensive, thought not terribly so. His abdominal exam was notable for lower abdominal tenderness which did not lateralize; there was guarding present but no rebound tenderness, with an absence of bowel sounds. Multiple trauma patients were occupying the CT scanner and would be expected to do so for the foreseeable future. The surgeon on call was contacted and was reluctant to come see the patient without a CT scan. What finding is visible on the above plain film of the abdomen that might convince him to expedite his evaluation of the patient?

Please put your answers in the comments. First correct answer wins a genuine karmic invisishirt! Scanman and other radiologists are excluded from the competition, but may email me directly to establish their superiority. Just for the record, I did pick this finding up myself. (and as they say, if the ER doc can see it...)

06 January 2009

I hear that there is a championship game coming up shortly. I love football, and I love college football. But it is January 7th, and I no longer care about bowls. They're supposed to end Jan 1. (I'll give you till the 3rd if it's a weekend.) It's playoff season now, you see? So I am sorry to tell you that I will not be watching your little title game. Maybe next year, if you keep it in the holidays where it's supposed to be, I will.

04 January 2009

It's been a solid two weeks since I posted for real on the blog. It took a little restraint at first; every stray thought I had seemed like the perfect topic for a blog post. Eventually I was able to free my mind from the thrall of my cybernetic overlords. Also, I skied. It was a nice time -- family, presents, fine wine, and the enduring joy of repeatedly digging four-wheel-drive vehicles out of snowbanks. I hope you also had nice holidays.

Now I'm back in the harness and will get back to you with some real medical posts soon enough. For the moment, I will throw in my $0.02 on a debate regarding the role of Mid-level providers (MLPs) in the ED, specifically NP's and PA's. Scalpel has made his point in spades, here, here, here, and here, while Ten out of Ten has provided a counter-point here, and Happy the Hospitalist chimed in over here.

Disclaimer -- I am not an expert in licensing requirements, liability, or reimbursement other than in my particular state. Also, there is variability in both the MD and MLP populations -- I've known PAs who were exceptional clinicians, and MDs who were, we joked, "licensed to kill." And vice versa. Your mileage may vary. I'm not interested in a "PA's suck!" "No, doctors suck!" argument. Having said that, I will dive in:

What is a PA or NP? First of all, it's important to understand that in most states, they are "Licensed Independent Providers," which means that they are qualified to examine and treat patients and bill for their services without direct physician oversight. PAs generally need a nominal supervising physician, and state laws vary as to how close the supervision need be. In our state, the doc must be physically on the premises except in critical access locations. NPs have less restrictive requirements. Both NP and PA training programs are highly competitive, and in most cases will only accept applicants with significant healthcare experience (the consequence is that the MLP ranks are full of former nurses, paramedics, and corpsmen). The training can be as little as 2 to 4 years (not counting prerequisites), and yields a masters-level degree. In my experience, the intensity, depth and breadth of the training is substantially less than that in medical school and residency, and the lack of standardized post-graduate training for MLPs requires significant on-the-job learning for new graduates.

The consequence of the more superficial education of MLPs is that they are usually required to function within a narrowly defined scope of practice. In an ER, that may be limited to minor traumatic injuries and other simple complaints. I have known PAs who were highly specialized as vascular or neurosurgery assistants; their understanding of their field far exceeded my own, but they functioned as extenders of their supervising docs and bore limited independent responsibility. For an MLP, knowing your scope of practice and staying within it is essential. (The same principle applies to physicians, I might add, though our scope is comparatively expansive.)

How are MLPs utilized in ERs? This is highly dependent on local and institutional issues and on the experience and comfort level that a department may have with MLPs. The most restrictive environments require the PA to present all cases to a doc and require the doc to see the patient as well -- in essence, this has the PA function like a resident physician. In other cases, the PA just has to present the patient, with the doc electing to see or not see them as they feel is indicated. Some EDs just have the docs review and co-sign all the PA charts, and others have a QA process by which a random sample of the PA charts are reviewed retrospectively. The more autonomously the MLPs operate, the more efficient it is, but that must be balanced by how well the scope of practice is adhered to and how much risk there is that a MLP might get in over his or her head with an unexpectedly complex patient. In a well- run ER, there is ample opportunity (and no disincentive) for MLPs to consult with or transfer care to a physician, as needed. My opinion is that with experienced MLPs and a carefully selected patient population, it is possible to safely run a fast track with completely independent MLPs.

Why are MLPs staffing ERs at all? The primary reason is economic, though as Scalpel noted, there is a shortage of qualified EM physicians which also is an incentive for ERs to hire MLPs if their patient demographics make sense. But the main reason is economic. Consider a PA working a site where the volume is not terribly high -- 2.5 patients per hour. Fast Track acuity typically translates to an average value of about 2.5 RVU per patient. So the PA is bringing in 6.25 RVU/hour, which at a conservative $40/RVU collection rate is $250/hour. Subtract $50 for expenses and pay the PA $60/hour, and the remaining $140/hour is profit for the employer. Incentivize your MLPs so they are a little faster, and your profit margin only goes up. This is an effective subsidy to the physician income base, one of the few refuges available in an era of shrinking reimbursement.

Speaking of reimbursement, how does that work for MLPs? That depends entirely on the internal policies of each individual patient's payer. When a PA sees a patient, it is coded with the ICD-9 and CPT codes based on their documentation, just like when a doctor sees a patient. However, some payers do and some do not issue provider ID numbers to PAs. Medicare and most governmental payers do issue provider IDs to PAs, and if the PA is the sole provider listed on the billing form, will reduce the allowable fee by 15%. Most commercial payers, in my experience, also do credential PAs, and pay at the same rate that they do for physician services, though some may apply a random reduction in the allowable (read your contracts!) between 5-20%. Medicare will pay an E/M code at the physician rate if it is a shared service, meaning that there must be documentation that the physician had (at a minimum) a face-to-face interaction with the patient. However, procedure codes, from lacerations up to and including Critical Care, may not be shared services and will be paid at the rate of the provider who actually performed the procedure. Thus if you think you can improve reimbursement by documenting that you supervised a PA's laceration repair, think again!

If the payer does not allow a charge to be billed in the PA's name, then the charge will be issued in the name of the supervising physician with the PA listed in the second position on the billing form (this will be ignored by the payer, but is necessary for internal record-keeping). Usually these get paid at 100% of the allowable.

Scalpel made a strange argument that MLP services should be at a steep discount from physician rates. While this would be a great way to eradicate MLPs from the health care landscape, I don't see much validity to this. A service provided is a service provided, and the worth of the service, performed competently, does not vary according to the credentials of the individual who provides it. A laceration repair is not worth more to the patient if the doc does it. A chest tube pays the same whether the surgeon or I put it in. Scalpel and I get paid the same though I am AEBM ABEM certified and he, apparently, is not. As far as I can tell, the only rationale behind the 15% holdback from CMS for MLP services is, "Because we can."

What about the vicarious liability implications of using MLPs in the ED? Obviously, there is always liability, but it is generally low. MLPs are under-represented in ED med-mal cases, and given the lower acuity of the patients they see, that makes sense, as does the fact that in most cases the dollar amount at stake is low. If you as the supervising physician never saw the patient, then you can seek to have your name dropped from the case due to absence of doctor-patient relationship. You may be on the hook for negligent supervision, but that is more commonly directed at your mutual employer. There are occasional cases in which a doctor who never saw the patient is found to have some responsibility, but that is more typically in cases where something else happened (an unlicensed PA, or falsification of the chart). In my experience (fortunately quite limited) it is fairly uncommon for the doc to even be named, if they never laid eyes on the patient.

What's the big picture? Scalpel thinks we should "Just Say No to Fast Tracks," and he's partly right. There is a significant added expense when minor ailments are treated in the ER (which is to say that Fast Tracks are profit centers for physicians and hospitals). Given that cognitive services are undercompensated relative to the real work and risk that go into them, it is essential for ER groups to retain the simple cases to cross-subsidize the work on the complex, sick patients. Also, given the ongoing collapse of primary care, it is becoming progressively more difficult for patients to receive care for acute illnesses and injuries at their doctors' offices, and the ER is an attractive one-stop-shop for patients. You can be in and out in a well-run Fast Track in ninety minutes. The macro-economic climate ensures that the customer demand is there, and we do nobody any favors by refusing to meet that demand. In an ideal world, when primary care physicians are well-paid and plentiful, perhaps that demand will cease to exist and the patients will all go back to outpatient centers. Or, more likely, CMS will cut reimbursement for Type B ED services (aka Fast Track) and hospitals will no longer have an incentive to grow that service line. From a queuing theory perspective, Fast Tracks (and the MLPs that run them) are essential at clearing out the lower rungs of the acuity ladder. It's short-sighted and vindictive to insist that less-urgent patients must wait until the truly sick have been seen. Run a good fast track, and everybody gets seen faster.

My personal opinion is that while I have nothing against PAs, in an ideal world, I would not employ them. It makes the management of a group more difficult to have two different classes of providers at different wage scales, and there is an inevitable tension between the two groups which I find is not conductive to good morale. The economic argument, however, is very compelling, and the decrease in income were we to change to an all-physician model would be painful indeed. Besides, we are not building an organization from a clean sheet of paper; we have had PAs for a couple of decades, they are good friends and colleagues who deliver good care, and their place in our organization is quite secure.

01 January 2009

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

All Content is Copyright of the author, and reproduction is prohibited without permission.